EmailMe Form - LIFESTYLE ASSESSMENT FORM

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Email

Age

Sex

What is your purpose in coming? *

Have you ever been diagnosed with an ailment/illness related to your health concerns? *

Have you suffered any trauma or loss in the last 5 years? *

What level stress do you feel you are experiencing at this time?

minimal

average

considerable

unbearable

How does stress manifest itself?

How many hours on average do you sleep daily?

Do you feel well rested?

Are you currently taking any medications?

yes

no

List names of medication:

List reasons for medication:

Please list any vitamins, minerals, herbal or homeopathic remedies your are currently taking and the dosages:

Do you have any allergies or sensitivities? If so please list them:

Have you ever been diagnosed with an illness? Please explain.

Do you have any food sensitivities, allergies, or dislikes?

How often do you have a bowel movement?

Do you strain to have a bowel movement?

Do you have loose bowel movements?

Do you experience any symptoms if meals are missed? Please explain:

Do you experience any symptoms after meals? Please explain:

Are you satisfied with your weight?

FEMALES ONLY:
Are you or could you be pregnant?

yes

no

Are you peri-menopausal or menopausal?

yes

no

Are you experiencing any menopausal symptoms? If yes, please explain: